Looking Ahead: The Future of American Health Care Ezekiel J. Emanuel, M.D., Ph.D.
US Health Care Spending (2016) $3.4 Trillion
Rx for Cost Cutting GDP (nominal) in 2016 Rank USA $18.57 trillion #1 CHINA $11.22 trillion #2 JAPAN $4.94 trillion #3 GERMANY $3.47 trillion #4 UK $2.63 trillion #5 FRANCE $2.46 trillion #6 INDIA $2.26 trillion #7
Two Trends Measure USA FRANCE GERMANY Health Care Cost per person (2015, PPP) $9,451 $4,407 $5,267 Average Life Expectancy 79.3 (31 st ) 82.4 (9 th ) 81.0 (24 th ) Infant Mortality (per 1,000 births) Cancer 5 year survival Breast Colon Childhood Leukemia Years of life lost (per 100,000 inhabitants aged 0-69) WHO Health System Ranking* 5.80 3.30 3.20 88.6% 64.7% 87.7% 86.9% 59.8% 89.2% 85.3% 64.6% 91.8% 4,600 3,100 3,000 37 1 25 * Based on a composite score of health, health inequality, responsiveness-level, responsiveness distribution, and fair financing.
Percentage Affordability Index 35% Family Health Insurance Premiums as Percentage of Median Income (2001-2015) 30% 26.9% 27.9% 30.1% 30.9% 31.5% 31.4% 31.0% 25% 22.4% 23.5% 23.8% 24.1% 25.2% 20.9% 20% 18.9% 16.7% 15% 14.2% 15.3% 10%
Unnecessary Services Source: Scott Ramsey. How Should We Define Value in Cancer Care. IOM Affordable Cancer Care Workshop. 8 Oct, 2012.
Inefficient Care Breast Cancer Irradiation Outcomes by Treatment Duration 5-year local recurrence-free survival Excellent/good global cosmetic outcome at 3 years Excellent/good global cosmetic outcomes at 5 years 3 Weeks 7 Weeks 97.2% 96.8% 76.8% 77.0% 76.8% 77.4% % Women receiving 34.5% 65.5% *No difference in overall survival rates was detected between study arms. Whelan T, MacKenzie R, Julian J et al. Randomized trial of breast cancer irradiation schedules after lumpectomy for women with lymph node-negative breast cancer. J Natl Cancer Inst. 2002; 94(15):1143-50.
Inefficient Care Robotic-assisted radical nephrectomies had longer operating times, higher hospital costs, and no better outcomes than laparoscopic surgeries. JAMA. 2017;318(16):1561-68. doi:10:1001/jama.2017.14586
Pricing Failures Medicare pays $2,062 for cardiac imaging done inhospital, compared to $626 done inoffice. $105 billion per year.
Enactment of Health Care Reform Patient Protection and Affordable Care Act March 23, 2010
Access
Cost
Cost Health care price growth dropped to 2-year low of 1.2% in August 2017 Source: Altarum Institute
Quality AHRQ : 21% reduction HACs from 2010 to 2015 125,000 fewer deaths 3.1 million fewer incidents of harm Approximately $28 billion in savings
The Iron Triangle Cost Quality Access
Quality The Cost-Quality Tradeoff High quality Low quality Higher cost Lower cost Cost Effectiveness
1-Month Ne Change Job Growth 600 Monthly Change in Total Private Employment (in thousands), 2008-2017 400 366 200 0 5 14 51 226 204 227 110 204-200 -400-600 -800-816 -1000 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Year Adapted from Bureau of Labor Statistics
VC Investments 2006 2010 $47.0 bn 2011 2015 $61.9 bn 32% growth Source: Pitchbook
What will the future of American health care look like?
The Way Forward
I ve always been independent. Always been the one helping everyone else. Now I can t do nothing for myself I m ready, I ve been ready ever since I had my heart attack. Ready whenever the Good Lord is ready to do His work. ~ Ms. Harris
The 12 Practices Scheduling Lifestyle interventions Registration & rooming Community interventions Hospice & Palliative Care Performance measurement Behavioral health management Shared decisionmaking Standardization Deinstitutionaliz ation Care management Site of service
2 Key Practices We will focus on: 1. Chronic care coordination 2. Behavioral health
Chronic Care Coordination 36% of Americans (117 million) have 1+ chronic conditions. 86% of all health expenditures are for people with chronic conditions. High-need, chronically ill U.S. adults spend $21,000 per year, 4x more than average adults.
Chronic Care Coordination
Chronic Care Coordination Identify high-risk patients Embed care managers in primary care teams Empower care managers to close care gaps Use active outreach to contact patients and improve compliance/acces s in case of complications Educate patients about their illness, adherence, and how to use the health system
Chronic Care Coordination Our number one complaint is that they [patients] hear from us too much. We are trying to streamline the calls and the appointment, so that you know that you re getting these [high-risk] patients in early and often. Dr. Sachin H. Jain, CareMore CEO
Behavioral Health This woman had postpartum depression and was suicidal. She insisted she would not see a psychiatrist.
Behavioral Health Monthly Health Care Expenditures for Chronic Conditions, With and Without Comorbid Depression, 2005 $1,290 $1,420 $840 $860 $20 $130 Mental health expenditures Medical expenditures Total expenditures Without depression With depression Adapted from Melek S & Norris D (2008). Chronic conditions and comorbid psychological disorders. Cited in: Druss BG & Walker ER (2011). Mental Disorders and Comorbidity. Research Synthesis Report No. 21. Princeton, NJ: The Robert Wood Johnson Foundation.
Behavioral Health The 3 Approaches to Behavioral Health: 1. Co-locating behavioral health specialists in PCP and specialist offices 2. Connecting PCPs with behavioral health providers who have unused appointments 3. Utilizing virtual medicine to do remote consults
Behavioral Health Mike Nagoshi, MD This woman had postpartum depression and was suicidal. She insisted she would not see a psychiatrist. At the end of our appointment, I asked her to accompany me down the hall. I then introduced her to the health psychologist who works in our office space. Right then, he began seeing her.
Behavioral Health David Wennberg, MD
What about Virtual Medicine?
Virtual Medicine Over the past decade, smartphones have radically changed many aspects of our everyday lives, from banking to shopping to entertainment. Medicine is next Just as the printing press democratized information, the medicalized smartphone will democratize health care. Anywhere you can get a mobile signal, you ll have new ways to practice data-driven medicine. Patients won t just be empowered; they ll be emancipated. ~ Eric J. Topol, MD
Role of Virtual Medicine A 2016 JAMA-IM study looked at effects of wearable tech. 1437 Patients hospitalized with CHF Usual care Health coaching phone calls with wireless blood pressure, heart rate, weight, and symptom, monitoring. Nurse initiated protocolized interventions.
Role of Virtual Medicine There were no significant differences between the two groups in: 30-day readmission 180-day mortality JAMA IM, 2016
Role of Virtual Medicine Virtual medicine cannot replace physician-patient relationships. It is best designed to work in the background.
Applications of Virtual Medicine Tele-ICU Text message communication Behavioral health Rural health Minor care resolution MD-MD consultation Follow-up care for chronic conditions
Phasing in the 12 Practices No single practice or health system has implemented all 12 practices. Instead, it is important to prioritize starting with a few key practices. Scheduling Chronic care management Performance management Site of service
Timeline of Transformation
Timeline of Transformation ACOs Source: David Muhlestein, Robert Saunders, and Mark McClellan. Medicare Accountable Care Organization Results For 2015: The Journey To Better Quality And Lower Costs Continues. Health Affairs Blog. September 9, 2016
Timeline of Transformation In the beginning, a big share of the savings was associated with changing site of service By year four, it was 50% price, 50% utilization in terms of how we were saving. ~ Dana G. Safran, Chief Performance Measurement & Improvement Officer, BCBS MA
Timeline of Transformation We found surprisingly strong sentiment that the industry will be transformed over the next five to ten years by the development of new pricing models broadly known as value-based care the responses indicated that value-based care may have even more of an impact on the industry than scientific breakthroughs. ~ Lazard 2017 Global Healthcare Leaders Study
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